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# Brilinta (ticagrelor)
## Overview
Ticagrelor is an orally administered, direct-acting, reversible P2Y12 platelet inhibitor. It is used to reduce the rate of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI).
## Primary Indications
* Reduction of thrombotic cardiovascular events (including myocardial infarction and stroke) in patients with acute coronary syndrome (ACS).
* Reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI) who are treated with aspirin.
## Adult Dosing
* **ACS:** An initial loading dose of 180 mg orally once, followed by 90 mg orally twice daily for at least 12 months.
* **History of MI:** 60 mg orally twice daily.
* **Aspirin:** Ticagrelor should be used in conjunction with aspirin. The recommended maintenance dose of aspirin is typically 75-100 mg daily. Higher doses of aspirin may reduce the efficacy of ticagrelor and should be avoided.
## Pediatric Dosing
There is no established pediatric dosing for ticagrelor.
## Dose Adjustments
* **Hepatic Impairment:** No dose adjustment is needed in patients with mild to moderate hepatic impairment. Caution is advised in severe hepatic impairment.
* **Renal Impairment:** No dose adjustment is needed in patients with mild to moderate renal impairment. Caution is advised in severe renal impairment.
## Contraindications
* Hypersensitivity to ticagrelor or any of its excipients.
* Active pathological bleeding.
## Adverse Effects
* **Bleeding:** The most common and serious adverse effect. This includes fatal or life-threatening bleeding, as well as other bleeding events (e.g., epistaxis, ecchymosis, gastrointestinal bleeding).
* **Dyspnea:** Shortness of breath is common and usually transient.
* **Bradycardia:** Can occur, particularly in patients concomitantly taking medications that cause bradycardia.
* **Hyperuricemia and SCr increase.**
* **Ventricular pauses** have been observed.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Strong inhibitors can increase ticagrelor concentrations, and strong inducers can decrease them.
* **P-glycoprotein (P-gp) Inhibitors:** Ticagrelor is also a P-gp substrate.
* **Other Antiplatelets/Anticoagulants:** Concomitant use increases the risk of bleeding.
* **Medications causing bradycardia:** Increased risk of symptomatic bradycardia.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for signs and symptoms of dyspnea.
* Monitor for SCr and uric acid levels periodically.
* Monitor for bradycardia.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, meaning its effects are less persistent than clopidogrel after discontinuation.
* Discontinuation of ticagrelor, particularly before completion of therapy, may increase the risk of thrombotic events.
* Patients on ticagrelor may experience dyspnea, which does not appear to be associated with underlying cardiac or pulmonary disease.
* The 90 mg twice daily dose in ACS is supported by strong clinical trial data. The 60 mg twice daily dose is approved for patients with a history of MI.
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***Disclaimer:** This information is intended for clinical pharmacists and healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines before making any therapeutic decisions. Dosing and recommendations may vary based on individual patient factors and local protocols.*
